DSWD-RLA Form 3

Republic of the Philippines

Department of Social Welfare and Development
APPLICATION FOR ACCREDITATION OF
SOCIAL WELFARE AND DEVELOPMENT PROGRAMS AND SERVICES

Date: _______________________
Type of Applicant :
(Please check the appropriate box)

Status of Application:

Mode of Service Delivery

DSWD

New Application

Residential Based

LGU

Renewal

Community Based

Private SWDA

Social Welfare Agency

Resource
Agency
Providing
Direct
Services

DSWD
Previously
Issued
Accreditation:
Certificate No: _ ______________
Date of Issuance: ______________
Date of Expiration: _____________

I. Identifying Information:
1. Name of Agency
_________________________________
_________________________________
_________________________________
3. Agency Head
_________________________________

2. Business Address:
_______________________________________
(No., Street/Subdivision, Barangay)

_______________________________________
(Municipality/City)

_______________________________________
(Province)

4. Position Title/Designation
_________________________________

5. Telephone/Mobile/Fax Numbers
_________________________________

6. E-mail Address
_________________________________
7. Registration/Perm[=it No:
71. SEC No: ____________________
7.2. CDA No. ____________________
7.3. Mayors Permit No. ____________
7.4. DSWD Reg & Lic No.__________

6. Website:
_______________________________________
8. Date of Issuance of Registration/Permit
8.1 SEC Issued: ________________________
8.2. CDA Issued: ________________________
8.3. Mayors Permit Issued: _______________
8.4. DSWD Reg & Lic Issued._____________

Reminder:

Private SWAs and Resource Agencies providing direct services are required to be accredited by the DSWD six (6) months
after the issuance of registration and license to operate.

DSWD, LGUs, NGAs and GOCCs implementing social welfare and development programs and services are required to
apply for accreditation within three (3) months from date of DSWD notification.
(Please use additional sheet/s, if necessary)

II. Specific Objectives of the Agency (pls. state):

1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________
6. ____________________________________________________________________________
III. Program Profile:
Target Clientele

1. Direct Program/s (pls. specify all the programs and services that is directly provided to the clientele per area of operation)
a. Community-based

b. Residential-based (pls. indicate specific name of each facility and services provided to the clientele)

Others
(Specify)

Disasters
Victims

Commun
ity

Family

PWD

Older
Person

Youth

Children

Municipality

City/
Province

Women

(Please check the appropriate column)

(pls. specify)

Region

Type of
Programs and
Services per
Service Delivery
Mode

Area of
Coverage/Location

IV. Personnel (current year)

No and Composition
Technical Staff
of Staff Complement

Administrative Staff

Registered
Social Worker

Community
Development Worker

Full time/
Regular Staff

Part time Staff

Volunteer Staff

V. Budget:
1. Annual Budget (Latest):_______________________________________________________
2. Source of Funds: (Please specify the SWDAs specific sources of funds whether government or
private organizations/individuals, local and/or international/foreign including other resource
generation activities with the corresponding amount of funds in peso value.)
a. Local Source

Peso Value

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

b. Foreign Source

Peso Value

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

_________________________________

_____________________

I hereby certify that the information on this application form is true and complete.
________________________________________________________________________
(Signature Over Printed Name of the Agency Head or Authorized Representative)

______________________________________________________
(Position/Designation of the Agency Head or Authorized Representative)

________________________________
(Date)